What is MDM in E&M coding?
MDM is medical decision making: the measure that sets the level of most office visits since the 2021 E&M revision. 3 elements decide it, and a level is met when 2 of the 3 support it.
Written by Dr. Tattvam A. Nair, Co-Founder & COO of Layrd. Updated August 2026.
The 3 elements
| Element | What counts |
|---|---|
| Problems | The number and complexity of problems addressed at this visit. Addressed, not carried on the problem list. |
| Data | Notes reviewed, tests ordered and interpreted, outside records examined, independent historians, discussions with other clinicians. |
| Risk | The risk of the management chosen: prescription management, decisions about hospitalization or surgery, social determinants that change the plan. |
Each element is graded, and the visit level is set by the 2 highest. Time is the alternative path: total time on the date of the encounter, including the chart review before the room and the documentation after it, can set the level instead.
Why practices undercode
The work happens and the note does not show it. Reviewing 4 outside documents before the visit is data complexity, but only if the note says so. Managing 2 chronic conditions and adjusting a prescription is moderate MDM, but only if both appear as addressed. The safe habit of defaulting to a 99213 is a quiet discount applied to work already done, visit after visit.
What defensible looks like
A defensible code is one you can trace. Each MDM element points at a line in the note, and the note actually contains the line. When the justification is written at the same moment as the documentation, the code and the chart cannot drift apart.
Where Layrd fits
Layrd codes the visit as the note is written: the E&M level with its full MDM justification, HCC mapping, and care gap capture, every element cited back to the chart. The physician sees why the code is what it is, and so does anyone who audits it later.
What is the difference between a 99213 and a 99214?
The MDM level. A 99214 requires moderate complexity in 2 of the 3 elements. Two stable chronic conditions managed with prescription medication commonly meet it. The same visit documented as a single problem with no data reviewed reads as a 99213.
Can a visit still be billed on time?
Yes. Total time on the date of the encounter, including chart review, documentation, and care coordination outside the room, can set the level instead of MDM. Whichever path is used, the note has to show the work.
What is undercoding?
Billing below the level the documentation and the work would support, usually out of audit caution. It is a recurring discount on work already done, and it compounds across every visit of every day.
Does Layrd justify the E&M level?
Yes. The E&M code comes with its full MDM justification, drawn from the note as it is written, and every element cites the documentation it rests on.
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